Please answer all the questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None". This is important! *The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40, but less than 70 years of age.

Give a Complete Record of all employment for the past three years, including any unemployment, or self employment, and all commercial driving experience for the past ten years.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on the highways in the interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

Driver Applicants Only

Straight Truck

Tractor and Semi-Trailer

Tractor and Two-Trailer

Tractor and Three Trailer

Other

Driver Applicants Only

(other than parking violations)

(List each driver's license held in the past three years)

Driver Applicants Only

CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (see Section 40.25(b)(5) and (e).

As an applicant, applying to preform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.

Initialing below certifies that the information provided is true and correct.

Driver Applicants Only

RECEIVED, subject to the classification and lawfully files tariffs in effect on the date of the issue of this Bill of Lading, NOT to be used for ORDER NOTIFY SHIPMENTS.

IMPORTANT - Please Use Zip Codes

NOTE: Where the rate is dependent on value, shippers are required to state specifically in writing the agreed or declared value of the property. The agreed or declared value of the property is hereby specifically stated by the shipper to be not exceeding:

Subject to Section 7 of the conditions, if this shipment is to be delivered to the consignee without recourse on the consignor, the consignor shall sign the following statement.The carrier shall not make delivery of this shipment without payment of freight and all other lawful charges.

This is to certify that the above-named materials are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of the Department of Transportation.